Orthopaedic Physical Therapy
Residency Application
APPLICANT INFORMATION
Date of Application:
Last Name:
First:
Middle:
Prior Names Used (Maiden Name):
Credentials (PT, DPT, OCS, etc):
Date of Birth: (mm/dd/yyyy)
If you haven’t already done so, please establish a MyEIM account (free) at: http://my.evidenceinmotion.com/MyEIM.aspx
If you already have a MyEIM account, please make sure your information is current.
COHORT
Choose a preferred start date:
Winter (January) 2014
Summer (July) 2014
Spring (March) 2014
Fall (September ) 2014
EMPLOYMENT INFORMATION (ALL FIELDS REQUIRED BY ALL APPLICANTS)
N/A, I am currently a student. This section does not apply.
Are you employed by an EIM Partner (Click here for list of EIM Partners: my.evidenceinmotion.com/eimpartners.aspx)?
Yes
No
Current Employer/Clinic Name:
Work Email Address:
Work Phone Number:
Work Address:
Work City:
Work State:
Work Zip:
Which of the following best describes your current primary position?
Academic administrator or director of PT/PTA education
program
Academic Faculty Member
Consultant
Director of Residency/Fellowship program
Partner in PT practice or business
Researcher
Sole owner of PT practice or business
Staff PT
Supervisor/Director of PT practice
Other _____________________________
Please estimate the number of hours per week you currently spend in clinical practice providing physical therapy services for
patients. (Note: Include time spent in administrative aspects of providing patient care such as scheduling, coding, documentation,
etc. as time spent in clinical practice.)
0-10 hours/week
11-20 hours/week
21-30 hours/week
31-40 hours/week
40+ hours/week
How many years have you been active in clinical practice?
For those Employed by an EIM Network Partner, please continue to page 3: Weekend Intensive Locations
RESIDENCY MODEL (REQUIRED FOR THOSE NOT EMPLOYED BY AN EIM PARTNER)
Evidence In Motion offers 2 Orthopaedic Physical Therapy Residency Models for physical therapists not employed by one of
our Program Partners. Please review and designate your choice below.
EIM’s Independent Residency
EIM’s Hosted Residency
 You choose where you will live and work. It is not
necessary to relocate.
 You negotiate salary and possible tuition subsidies with
your employer.
 You may qualify for Loan Deferment to allow you to
enjoy the benefits of an earned income while pursuing
your Residency.
 You choose your mentor and the location of mentorship
(both must meet EIM criteria).
 This Independent Residency program is designed to
take 18 months to complete (it may be extended up to
36 months).
 You incorporate self-scheduled “learning time” into your
week.
 Residents in this model typically work a full time
schedule and are established in their clinical practice
and/or community.
 During the course of the 18-month program, you will
need to travel to 4 Weekend Intensive Labs (see WI
locations below).
 The Residency program will prepare you to sit for your
OCS Exam with an OCS Capstone Course that has
shown an 87% pass rate.
 You are able to add a Postprofessional DPT or
Certification (Manual Physical Therapy or Sports Physical
Therapy) to your plan of study with just a few courses.
The Residency is also an excellent way to prepare for
EIM’s Orthopedic Manual Physical Therapy Fellowship
Program.
 Upon program completion you will continue with your
current employment contract and advancement
opportunities.
 You choose to live and work with one of EIM’s preferred
clinical residency sites which may require you to relocate.
(*See below for site opportunities)
 You benefit from a competitive resident salary with fully
subsidized residency tuition.
 You may qualify for Loan Deferment to allow you to enjoy the
benefits of an earned income while pursuing your Residency.
 Your mentor has been pre-approved by EIM and will provide
mentoring onsite.
 The Hosted Residency program is designed to take you
through an accelerated curriculum in 12-14 months.
 You will be given ~4 hours/week of dedicated “learning
time”.
 Residents in this model are typically a new graduate or a PT
searching for a different job opportunity that includes “inresidence” Residency training.
 During the course of the 14-month program, you will need to
travel to 4 Weekend Intensive Labs (see WI locations below).
 The Residency program will prepare you to sit for your OCS
Exam with an OCS Capstone Course that has shown an 87%
pass rate.
 You are able to add a Postprofessional DPT or Certification
(Manual Physical Therapy or Sports Physical Therapy) to your
plan of study with just a few courses. The Residency is also an
excellent way to prepare for EIM’s Orthopedic Manual
Physical Therapy Fellowship Program.
 Upon program completion you will have the potential
opportunity for full-time employment at your residency site or
the ability to move on to new job opportunities.
Please choose the Orthopaedic Residency Model that best meets your needs.
I would like to join EIM’s Independent Residency
Program. I understand that I am responsible for my
own employment and tuition.
I would like to join EIM’s Hosted Residency Program. I
understand that I may need to relocate to my preferred
site.
For those interested in EIM’s Hosted Residency Program, please
visit our list of host site locations: at
http://my.evidenceinmotion.com/hostedresidencysites.aspx
If you are considering multiple sites, please designate your top
3 preferred site locations below.
Host
Site
1)
2)
3)
Clinic Name
Clinic Location
WEEKEND INTENSIVE SITE SELECTION
Weekend Intensive (WI) Locations : All EIM Management Courses are offered in dual track system. You will be assigned to
a curricular track based on your primary Weekend Intensive location.
Track A Program Management Course Sequencing: 1) Lumbopelvic Disorders, 2) Lower Extremity Disorders, 3) Cervical and
Thoracic Disorders and 4) Upper Extremity Disorders
Track B Program Management Course Sequencing: 1) Cervical and Thoracic Disorders, 2) Upper Extremity Disorders, 3)
Lumbopelvic Disorders, 4) Lower Extremity Disorders.
Please select and prioritize your first three choices for weekend intensive locations by listing a 1, 2, or 3 beside three of the
locations below. Please note that your final assignment of weekend intensive location will be based upon your
preferences indicated as well as site and space availability. You will be notified of your weekend intensive location(s) in
your acceptance letter and automatically enrolled for each management course.
Track A:
____ Arlington, Virginia (Mid Atlantic Consortium: consists
of Body Dynamics, Gold Medal PT, Loudon PT,
Restore Motion, Results Rehab & Fitness, and Total
Motion PT)
____ Atlanta, Georgia (Benchmark Physical Therapy)
____ Baton Rouge, Louisiana (Baton Rouge Physical
Therapy)*
____ Chicago, Illinois (ATI Physical Therapy)
____ Evansville, Indiana (ProRehab)*
____ Green Bay, Wisconsin (Bellin Physical Therapy)
____ Norman, Oklahoma (Physical Therapy Central)*
____ Ortonville, Minnesota (Big Stone Therapies)
____ Roseville, California (Sutter Health) & San Francisco,
CA
(San Francisco Sport & Spine) These 2 locations are a
* consortium that will alternate WI offerings in 2014
Track B:
____ Austin, Texas (Texas Physical Therapy Specialists)
____ Chicago, Illinois (AthletiCo)
____ Fresno, California (Terrio Therapy-Fitness)
____ Guilford, Connecticut (PTSMC) & Kingston, Rhode Island
(University of Rhode Island) These 2 locations are a
consortium that will alternate WI offerings in 2014
____ Tacoma, Washington (Apple Physical Therapy)
*This location will only offer one course in 2014, not all Weekend Intensives will be held at this site.
CONTACT INFORMATION (PLEASE DO NOT ENTER P.O BOX #. PHYSICAL ADDRESS NECESSARY FOR PROGRAM MATERIAL SHIPMENTS)
Student preferred Email Address:
Preferred Phone Number:
Secondary Email Address:
Secondary Phone Number:
Home Address:
City & State/Province/Territory:
(Please indicate if St, Ave, Rd, etc.)
Country:
Postal Code:
BILLING INFORMATION-PLEASE INDICATE WHO WILL HANDLE INVOICES/PAYMENT (PLEASE DO NOT ENTER P.O BOX #.)
*THIS SECTION MUST BE COMPLETED FOR APPLICATION TO BE PROCESSED
N/A, I am choosing the Hosted Residency Model
Self
Employer ____________________________________________________(person in charge of billing)
Email Address:
Phone Number
Address:
City:
(Please indicate if St, Ave, Rd, etc.)
State:
ACADEMIC BACKGROUND,LICENSURE AND CERTIFICATIONS
Zip:
What degree were you/will you be awarded upon completion of your entry-level PT education?
Baccalaureate
Name of Institution:
Master’s (MPT, MS, etc.)
DPT
Year of Graduation:
What is your highest earned PT related degree?
Baccalaureate
Post-Baccalaureate Certificate
Entry Level Doctorate (i.e. DPT, TDPT)
Name of Institution:
Entry Level Master’s (i.e. MPT, MS)
N/A, Current Student
Post Professional Clinical Doctorate (i.e. DHSc, DSc)
Other ______________________
Year of Graduation:
Please list physical therapy licensure information (*MUST PROVIDE COPY OF LICENSE WITH APPLICATION)
State:
License #:
Expiration:
N/A, Current Student
Students: When do you plan to sit for your Physical Therapy Examination (month/year)?________________________________
CPR Certification (*MUST PROVIDE COPY OF CERTIFICATE WITH APPLICATION)
Date:
Expiration:
Please list any previous APTA credentialed residency/fellowship programs that you have completed:
Program:
Practice specialty:
Year Completed
Clinical Electro-physiology
Residency
Hand
Fellowship
Manual PT
Orthopaedic PT
Pediatrics
Women’s Health
Please list any ABPTS board certifications you hold:
Practice Specialty:
Certification #
Expiration
Clinical Electro-physiology
Geriatrics
Neurological
Orthopaedics
Pediatrics
Sports
Women’s Health
PROFESSIONAL MEMBERSHIPS
Do you have a current APTA Membership?
Yes Member number : ________________
No (Required for Resident and Fellow Applicants, please apply for membership)
What sections do you belong to?
Acute Care
Home Health
Aquatic PT
Neurology
Cardiovascular & Pulmonary
Orthopaedic
Clinical Electro-physiology
Pediatric
Education
Private Practice
Federal PT
Research
Geriatric
Sports PT
Hand Rehabilitation
Women’s Health
Health Policy and Administration
Are you a member of the American Academy of Orthopaedic and Manual Physical Therapists? (AAOMPT)
Yes Member number: _________________
No
APPLICANTS TRAINED OUTSIDE OF THE UNITED STATES
1. Are you currently licensed in the United States?
Yes (Please list State, License #, and expiration__________________________________________________________________________)
No (Please see # 2 below)
2. If your answer to question 1 is No, all applicants who have graduated from a university outside of the US and who are not currently
licensed in the US must provide an official physical therapy degree equivalency evaluation for admission. The prospective student
will pay for this evaluation. EIM requires an evaluation for the Transition DPT program from one of the FSBPT (Foreign Educated
Physical Therapist Committee) approved agencies that use the Coursework Tool (CWT) to evaluate equivalency. The approved
agencies include the following:
- Foreign Credentialing Commission on Physical Therapy (FCCPT): http://www.fccpt.org/
- International Consultants of Delaware (ICD): http://www.icdeval.com/
- International Education Research Foundation, Inc (IERF): http://www.ierf.org/
- World Education Services (WES): http://www.wes.org/
1. Is the English language your (please check all that apply):
Native/first language
Language used in your physical therapy / physiotherapy education
Primary language for your daily professional / clinical practice
None of the above.
If English is not your First/Native language, what is your primary language?_______________________________________________
2. If your answer to the question above was "None of the above", then you will need to meet the following language proficiency
requirement:
- TOEFL (Test of English as a Foreign Language) – Internet-based: Minimum score of 82 on the TOEFL.
- TOEFL – Computer-based: Minimum score of 213.
- Paper-based: Minimum scores of 550.
- Note: Our TOEFL code is 7315, please place this on your application so that we receive your scores.
The TOEFL is administered by TOEFL/TSE Services, PO Box 6151, Princeton, NJ, 08541-6151, USA (609) 771-7100
Information is available on the Internet at www.toefl.org.
MENTORSHIP (REQUIRED FOR INDEPENDENT RESIDENCY APPLICANTS)
Clinical Mentor: Please designate a mentor to supervise the clinical practicum component of the Orthopaedic Residency program.
I do not have this information at this time. I understand it is a requirement for the program and I must submit my mentor
information to EIM no later than 8 weeks after the program start date.
Last Name:
First:
Clinic Name:
Clinic website:
Phone:
Email:
Evidence in Motion Residency and Fellowship programs are credentialed through the American Board
of Physical Therapy Residency & Fellowship Education (ABPTRFE). Students in these programs are
prohibited from participating in ANY clinical or supervised mentoring in a physician-owned or referral
for profit facility. Please contact EIM directly for further clarification on this policy.
By checking this box, I understand this policy and verify that I do not work in and will not conduct
clinical or supervised mentoring in a physician-owned or referral for profit facility.
* Acknowledgement is required for admission to the program.
PROFESSIONAL LIABILITY INSURANCE (REQUIRED FOR RESIDENCY APPLICANTS - PLEASE PROVIDE COPY WITH
APPLICATION)
Please provide your malpractice insurance information:
Carrier:
Policy Number:
Expires:
ORTHO RESIDENCY WITH POSTPROFESSIONAL DPT IN MUSCULOSKELETAL MANAGEMENT
Would you like to add EIM’s Postprofessional DPT in Musculoskeletal Management to your Orthopaedic Residency Program?
Yes
No
OFFICIAL TRANSCRIPTS FROM CAPTE ACCREDITED PROFESSIONAL PROGRAM (REQUIRED FOR COMBINED
POSTPROFESSIONAL DPT / ORTHOPAEDIC RESIDENCY APPLICANTS ONLY)
All applicants must have successfully completed a CAPTE accredited professional physical therapy curriculum, or have had a state
physical therapy board approve the applicant’s first-professional physical therapy program as “equivalent” to a US CAPTE accredited
professional physical therapy program.
Applicants from CAPTE accredited professional programs should request that official transcripts be sent directly to EIM from the
institution where the physical therapy degree was awarded. Official transcripts can be mailed or sent electronically. EIM accepts
electronic transcripts from the following services: Scrip-Safe, Docufide, Avow Systems.
I have requested that my official transcripts be sent to EIM and understand that my application will not be determined complete
until EIM receives the document(s).
POSTPROFESSIONAL DPT (TRANSITION) IN MUSCULOSKELETAL MANAGEMENT ACKNOWLEDGEMENT
All EIM Postprofessional DPT In Musculoskeletal Management Applicants must review EIM’s Postprofessional DPT Frequently Asked
Questions document, which describes EIM’s position on this degree. Please click link (or copy and paste into browser) to review.
http://www.evidenceinmotion.com/wp-content/uploads/2012/07/EIM-tDPT-FAQ_Postprofessionalv.3.pdf
By checking this box, I verify that I have reviewed and understand the linked document (above). I
recognize that although EIM is licensed as a proprietary educational organization and follows the APTA
Preferred Curricular Guide for its Postprofessional DPT, it is not a regionally accredited university.
* Acknowledgement is required for admission to the program.
FOCUS ON THERAPEUTIC OUTCOMES (FOTO)- (OUTCOMES TRACKING FOR RESIDENCY)
Do you have a current FOTO account that you use?
Yes (please provide your Clinic Name and Username:____________________________________________________________________
No, please sign me up for an account
HOW DID YOU HEAR ABOUT EIM?
How did you hear about EIM’s Orthopaedic Residency Program? Please check all that apply:
Advertisement
Online
JOSPT
Impact
Perspective
Orthopaedic Section
Email
Social Media
Mailer
APTA
Conference (please specify
which conference and when):
Friend/Colleague*
Professor*
Current EIM Program
Student*
Other (please specify):
*Please provide the name(s) and email address(es) for anyone who referred you to our program, so we may thank them!
Name:
Email:
STATEMENT OF INTEREST: REQUIRED FOR ALL APPLICANTS
REQUIRED ITEMS TO EMAIL / MAIL TO EVIDENCE IN MOTION: Please check to verify all submitted
Please fill out the application (ALL Applicants) electronically (i.e. MS Word) and save by using your
last name, a space, and then first name. If you really want to impress, then save or print these
electronically as a pdf file. Please e-mail the completed application forms to
admissions@eimpt.com. Applications can also be faxed to 1-866-936-2759.
An alternate option is to mail a hard-copy to:
Evidence in Motion
Attn: Application Submissions
17325 Bell North Drive, Suite 2B
Schertz, TX 78154-3368
Electronic or hard copy of Statement of Interest (All Applicants)
Electronic or hard copy of your current and valid Physical Therapy License(s) (All Applicants,
excluding current DPT students)
Electronic or hard copy of your CPR certificate (All Applicants)
Electronic or hard copy of Professional Liability Insurance (All Applicants)
Electronic or hard copy of your Physical Therapy degree equivalency evaluation (Applicants trained
outside of the US Only)
Please check here to verify your TOEFL submission with code 7315 (Applicants trained outside of the
US Only)
$100 Application fee, non-refundable (*REQUIRED FOR ALL APPLICANTS TO PROCESS APPLICATION)
*** Please call the billing office at 1-888-709-7096 to make all payments
Discount Promotion Code:______________________________________________________________________
STATEMENT OF EXPECTATIONS (*MUST BE SIGNED FOR APPLICATION TO BE PROCESSED)
The EIM Residency programs include a combination of distance-based and live on-site intensive course
components. This means that applicants should be technically proficient in basic internet use as well as
able to travel to the on-site intensive course events. By checking the box below, you acknowledge that
you have read this statement, understand its implications, and agree to the aforementioned conditions.
I agree to the above statement:
Yes
No
Signature:
(*SIGNATURE IS REQUIRED FOR APPLICATION TO BE PROCESSED)
Date:
Verification Email sent upon successful completion of application and payment
Once we receive your application and application fee ($100.00, non-refundable) you will be contacted
regarding your acceptance status. Acceptance letters will be sent 4 weeks prior to the cohort start date.
Please contact us at info@eimpt.com if you have questions on the residency or fellowship programs. Contact
us at TDPT@eimpt.com if you have questions specifically about our DPT program.
Thank you for applying. We look forward to the possibility of having you join our programs.
Sincerely,
The Evidence in Motion Team
Payment Information
A) Program Fees (per participant – please note that prices are subject to change).
Please refer to the EIM Website http://evidenceinmotion.com/pricepage.aspx for most current pricing.
All prices listed here are in US dollars, and all payments should be in US dollars.
Orthopaedic Physical Therapy Residency (OPTR)
OPTR + DPT Combined
1.
2.
3.
$ 12,650 (plus $100 application fee)
$ 13,800 (plus $100 application fee)
Postprofessional DPT tuition may be less if a revised Plan of Study, based on prior EIM coursework taken and PTET
scores, is approved.
Fees listed do not include travel related expenses for weekend intensives.
Actual tuition fees may be less if participant is affiliated with a current EIM Network Partner or Program Affiliate.
B) Orthopaedic Residency Program Course Waiver/Credit
Online and hybrid courses (multi-week online didactics with an onsite weekend intensive) taken through
EIM within the prior 36 months can be credited toward this program if requested.
Students attending an EIM Weekend Intensive course as a CE participant within two (2) years of applying
to an EIM program may receive a $300 tuition credit per course. While tuition credit is granted, the
student will be required to repeat the WI at no cost. This allows the student to take the WI as part of the
Management course and complete requisite skills check that are not required of a CE participant.